13100110 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7373 FALLENLEAF LN CONTRACTOR:FALLEN LEAF SS LLC PERMIT NO:13100110
OWNER'S NAME: FALLEN LEAF SS LLC 66 E SANTA CLARA ST DATE ISSUED: 10/15/2013
OWNER'S PHONE: 4083093519 SAN JOSE,CA 95113 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION: RESIDENTIAL 13, COMMERCIALE]
License Class Lic.# **APT#12**INSTALL(N)20 AMP CIRCUIT FOR
MICROWAVE/HOOD.ADD 1 (N)CAN LIGHT IN KITCHEN.
Contractor Date UPDATE ALL OUTLET RECEPTACLES FOR
I hereby affirm that I am licensed under the provisions of Chapter 9 GFCl/GROUNDING
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.: Sq.Ft Floor Area: Valuation:$800
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this APN Number:35927025.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS 1 LLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Issue Date: (O 1-3
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
RE-ROOFS:
Signature Date All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
OWNER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Was owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by t Bay Area Air Quality Management District I
performance of the work for which this permit is issued. will maintain compliance with t CB
' o Mu ipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sectitis 25505 5533, nd 2 4.
Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agen Date:
permit is issued.
A-fertify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so:as to become subject to the Worker's CO TRUCTION LE G AGENCY
Compensation laws of California. If,after making this certificate of exemption;I
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city,and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned ptoperty for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Addition y,the applicant understands and will comply
with all non-pt source regula i s per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signatu Date�b / , /
GENERAL PERMIT APPLICATION \ \O 'VI C r
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255 \�
MISCCUPERTINO (408)777-3228•FAX(408)777-3333•buildindCa�cupertino.org
PLUMBING MECHANICAL tRELECTRICAL MISCELLANEOUS
PROJECT ADDRESS .fl . APN#
OWNERNAME PHOW0g q .7572 1 E-MAIL
STREET ADDRESS CITY, STATE,ZIP FAX
CONTACT NAME - j E-MAIL
$.30< 3
STREET ADDRESS CITY,STATE,ZIP � FAX
P'o
❑OwNER OWNER-BUBAER ❑ owNER AGENT ❑ CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER ❑TENANT
CONTRACTOR NAME LICENSE NUMBER LICENSE TYPE BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL, FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
USE OF ❑SFD or DUPLEX ❑ MULTI-FAMLLY PROJECT INWIL DI,AND ❑ YESPROJECT IN ❑YES IS THE BLDG AN ❑YES
BUILDING: 13 COMMERCIAL URBAN INT WACE AREA ❑ NO FLOOD ZONE ❑NO EICHL.ER HOME? ❑NO
DESCRIPTION OF WORK 1
LA�k OC& :b
.`4 c
r
TOTAL VALUATION: / ItECt ICD BY "r
By my signature below,I certify toe f the fo owing: I am property owner or authorized agent to on the owne' I have read this
application and the information I hav p vided is rrect. I hav ad the Description of Work and ve It is accurate. I agree to comply with all applicable local
ordinances and state laws relating to 'ding ConAuction. I orize r resentatives of Cupertino to enter the abovg-id��d property for inspection purposes.
Signature ofApplicant/Agent Date: ( ` 1//�'S'j
UPPLEMENTAL Mor ION REQUIRED oxFiic � x r
W vi+;g T�pi7ivc 1
� D �izEss
' STANDARD
LY
p� f
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 7373 FALLENLEAF LN DATE: 10/15/2013 REVIEWED BY: MELISSA
APN: 359 27 025 --T `'VALUATION: $800
t` 0
*PERMIT TYPE: Electrical Permit PLAN CHECK TYPE: Alteration/Addition/ Repair
PRIMARY Buildina is FEIN IIAMATION 1 REAP11
USE: I Multi-Family Dwelling >3 Stories ® Yes (2) No PERMIT TYPE:
WORK **APT# 12**INSTALL N 20 AMP CIRCUIT FOR MICROWAVE/HOOD.ADD 1 N CAN LIGHT IN
SCOPE KITCHEN. UPDATE ALL OUTLET RECEPTACLES FOR GFCI/GROUNDING IN SERIES
APPLIANCE/EQUIP TYPE FEE ID QTY UNITS BP FEES
Fixtures, Lighting 1BREMFIXT 1 # $70
Recep/Switch/Outlets 1BREMRECEP 1 # $47
a g, ema' $117 00
TOTALS: _
E ,
Llectr. Non,Check Ptzttnb.Plan Check Elec.Plan Check 0.0 hrs $0.00
lectr.Pc:rruit Fee Plumb.Permit I ee: Elec.Permit Fee: IEPERMIT
Other;leech.Insp. other Plumb Insp. Other Elea.Insp. L.
hrs $47.00
AIc:ch.Imp.l<t c. Plumb. InsEr.Fee: Elce.Insp. Fee:
NOTE:This estimate does not include fees due to other Departments(Le.Planning,Public Works,Fire,Sanitary Sewer District,School
District et . These ees are based on the relimina in ormation available and are onl an estimate. Contact the Dept or addn'l in o.
c
FEE ITEMS(Fee Resolution 11-053 E 7f/ 11/13) FEE QTY/FEE MISC ITEMS
Plan'Check Fee:
Sulrpl. PC Fees
PME Plan Check: , $0.00
Permit Fee:
Suppl, Insp Fee
PME Unit Fee: $117.00
PME Permit Fee: $47.00
Construction Tax:
Administrative Fee: IADMIN $44.00
Work Without Permit? 0 Yes G:No $0.00
Advanced Planning Tees:
Travel Documentation Fee: ITRAVDOC $47.00
Strong Motion Fee: 1BSEISMICR $0.50 Select an Administrative Item
Bld¢Stds Commission Fee: IBCBSC $1.00
, � $256.50 $0.00 ll QT FEEy $256.50
Revised: 10/01/2013
v OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO,CA 95014-3255
(408)777-3228•FAX(408)777-3333•buildingecuoertino.org
+CUPERTINO
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS APN BP#
OWNER NAME OWNERADDR SS C
DESCRIPTION OF.WORKt.
We.are providing you with an'Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read,initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you,the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information)
0eer
1 understand a frequent practice of unlicensed persons is to have the property owner obtain an"Owner
"building permit that erroneously implies that the property owner is providing his or her own labor and material
ally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries.I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
M. I understand building permits are not required to be signed by property owners unless they are responsible for
thonstruction and.are not hiring a licensed Contractor to assume this responsibility.
3. 1 understand as an"Owner-Builder" I am the responsible party of record on the permit. I understand that.l may
r ect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
4. I understand Contractors are required by law to be licensed and bonded in California and to list their license
bers on permits and contracts.
I:understand if l employ or otherwise engage any persons, other than California licensed Contractors, and the
o I value of my construction is at least five hundred dollars ($500), including labor and materials, I may be
c nsidered an"employer"under state and federal law.
6. 1 understand If I am considered an"employer"under state and federal law, I must register with the state and
f eral government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
employment compensation for each"employee." I also understand my failure to abide by these laws may subject
4e to serious financial risk.
7. 1 understand under California Contractors' State License Law, an Owner-Builder who builds single-family
e idential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
PtsfeI understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
fc
ancial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
in the workmanship or materials.
OwneYBuilderForm 2010.doc revised 04/14/10
.i understand 1 may obtain more information regarding my obligations as an°employer"from the internal
R enue Service,the United States Small Business Administration,the Ca{iforia Department of Benefit Payments,
and the California D-nirslon of Industrial Accidents.I also understand I may contact the California Contractors'State
License Board(CSLB)at 1-800-321-OSLB(2752)or www csib.ca.gov for more information about licensed
1Y .
tors,
0-i am aware of and consent to an Owner-Builder building permit applied for in my name,and understand that I
party legally and financially responsible for proposed construction act-nrity at the site address listed above.
.1 agree that,as the party legally and financially responsible for this proposed construction activity,i will abide
pplicable laws and requirements that govern Owner-Builders as well as employers.
2:1 agree to notify the issuer of this form immediately of any additions, deletions,or changes to any of the.
Iation.i have provided on this form.Licensed contractors are regulated by laws designed to protect the public if
ntract with someone who does not have a license,the Contractors'State License Board may be unable to
assist you With-any finariciai.loss you may sustain as a result of a complaint.Your only remedy against unlicensed
Contractors mo be in civil court.It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property,you may be held liable for damages.If
you obtain a permit as Owner-Builder and wish to hire Contractors,you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers'compensation insurance coverage..
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please cdmplets the following construction lending agency information)
1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued
(Sec 3097 Civ.)
Lender Name: Lender Address:
Before a building penult can be Issued,this form must be completed and signed by the property,owner and
returned to the agency responsible for suing the permit. Note:A copy of the property owners driver's license,
form notarizaffon,or other verfffcafon a, pt�bl to the may be required to be presented when the permit is issued
to verifythe roe owner's sl nature.
Property Ownees Signature: Date:
- -------------------------------------- ------------- --------- -------------------------------------------------------------------
(NOTE: The following Authorrzafron Form is requf fo be completed by the property owner only when designating an
agent of the property owner to apply fora construction permit forthe Owner-Builder)-
AUTHORIZATION-OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner,the execution of which i understand is my personal responsibility, I hereby.
authorize the foilowing person(s)to act as my agent(s)to apply for,sign,and file the documents necessary to obtain an
Owner Builder Permit for my project.
Scope of Constiuction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
I declare under penalty of perjury that I am the property owner for the address listed above and i personally filled out the
above information and certify its accuracy_Note.A copy of the property owner's driver's license,form notarization, or other
verification acceptablelo the city=ulred to be presented when the permit is issued to verify the property owner's
signature. ^{Property Owner's Signature: �''� Date=.�o,IL
r l-3
OwnerBuitderForm_2010 doe reused 04/14110
' Building Department
City Of Cupertino
10300 Torre Avenue
'`Cupertino,CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR/SUBCONTRACTOR LIST
JOB ADDRESS: PERMIT#.
O WNER'S NAME: PHONE# Q.
GENERAL CONTRACTOR: BUSINESS LICENSE_#,�
ADDRESS: - CITY/ZIPCODE._;�J('A, .
*Our municipal code requires all businesses working in the city to have a City.of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPE'CTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A-CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information.` ..
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE#
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum/Wood
4'
Glass/Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
_ z
Sheet Metal,
Sheet Rock
Tile
i
Owner/ ractor Signature Date